1 A+ Pass
What information is taken during a Physical Exam? - Answers -✔✔ Objective data that
is collected using inspection, palpation, auscultation, and percussion
What is the importance of documentation of data? - Answers -✔✔ Helps to serve as a
baseline for the evaluation of subsequent changes and helps to make decisions related
to care
What are symptoms? - Answers -✔✔ Subjective characteristics of disease felt only by
the patient
What are signs? - Answers -✔✔ A collection of objective data completed by the nurse to
help figure out a diagnosis
What is a comprehensive health assessment and when is it preformed? - Answers -✔✔
Involves a detailed history and physical examination. Normally preformed at the onset of
care at a primary care setting or admission to a hospital or a long-term care facility.
What is Health History? - Answers -✔✔ A collection of subjective data that provides a
detailed profile of the patient's health status
What is a problem-based/focused assessment and when is it preformed? - Answers -
✔✔ Involves a health history and physical examination that is linked to a SPECIFIC
problem. Normally done at a walk-in clinic, ER, or other outpatient settings.
What is an episodic/follow up assessment and when is it preformed? - Answers -✔✔
Done when patient is following up with a healthcare provider for a specific problem. For
example, a patient with diabetes.
What is a shift assessment and when is it preformed? Why is it important? - Answers -
✔✔ Done when individuals are hospitalized. Nurses complete an assessment during
each shift, which is done to assess any changes in the patient's condition from the
baseline.
What is a screening assessment and when is it done? - Answers -✔✔ This is a short
examination used to detect diseases. Most likely done at a health care providers office.
What is context of care and how does it impact a health assessment? - Answers -✔✔
The context of care can be referred to as the general environment during a health
assessment. If the environment makes the patient feel unsafe, the health assessment
may not be completed or may not be completed correctly.
, What is patient need? How does it impact health assessment? - Answers -✔✔ Patient
needs could include age, general level of health, presenting problems, knowledge level
of healthcare, or even their support system. If the patient has poor levels of these, the
health assessment may be difficult to complete.
How does the experience of nurses impact health assessment? - Answers -✔✔
Different types of assessments may be needed to get an accurate gauge on the patient,
which requires knowledge and experience of a nurse.
What are the six steps in the nursing process? - Answers -✔✔ 1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
What are the three phases of the interview process? - Answers -✔✔ Introduction,
discussion, and summary.
What are the techniques used during the interview to enhance data collection? -
Answers -✔✔ Active listening, confrontation, clarification, facilitation, interpretation,
reflection, and summarization
What are five things that diminish data collection? - Answers -✔✔ Using medical
terminology, expressing value judgements, interrupting the patient, being
authoritarian/paternalistic, and/or using "why" questions
What are some methods of managing awkward situations? - Answers -✔✔ -Answering
personal questions (be brief)
-Silence (become comfortable with it)
-Displays of emotion (take a therapeutic approach)
What are four potential barriers/challenges to the interview process? - Answers -✔✔ -An
overly talkative patient
-Others in the room
-Disruptive individuals
-Angry/upset patients
Define each letter of OLDCARTS: - Answers -✔✔ O: Onset
L: Location
D: Duration
C: Characteristics
A: Aggravating/Alleviating factors
R: Related symptoms